Communication of palliative care needs in discharge letters from hospice providers to primary care: a multisite sequential explanatory mixed methods study.

BACKGROUND: The provision of palliative care is increasing, with many people dying in community-based settings. It is essential that communication is effective if and when patients transition from hospice to community palliative care. Past research has indicated that communication issues are prevalent during hospital discharges, but little is known about hospice discharges. METHODS: An explanatory sequential mixed methods study consisting of a retrospective review of hospice discharge letters, followed by hospice focus groups, to explore patterns in communication of palliative care needs of discharged patients and describe why these patients were being discharged. Discharge letters were extracted for key content information using a standardised form. Letters were then examined for language patterns using a linguistic methodology termed corpus linguistics. Thematic analysis was used to analyse the focus group transcripts. Findings were triangulated to develop an explanatory understanding of discharge communication from hospice care. RESULTS: We sampled 250 discharge letters from five UK hospices whereby patients had been discharged to primary care. Twenty-five staff took part in focus groups. The main reasons for discharge extracted from the letters were symptoms "managed/resolved" (75.2%), and/or the "patient wishes to die/for care at home" (37.2%). Most patients had some form of physical needs documented on the letters (98.4%) but spiritual needs were rarely documented (2.4%). Psychological/emotional needs and social needs were documented in 46.4 and 35.6% of letters respectively. There was sometimes ambiguity in "who" will be following up "what" in the discharge letters, and whether described patients' needs were resolved or ongoing for managing in the community setting. The extent to which patients received a copy of their discharge letter varied. Focus groups conveyed a lack of consensus on what constitutes "complexity" and "complex pain". CONCLUSIONS: The content and structure of discharge letters varied between hospices, although generally focused on physical needs. Our study provides insights into patterns associated with those discharged from hospice, and how policy and guidance in this area may be improved, such as greater consistency of sharing letters with patients. A patient-centred set of hospice-specific discharge letter principles could help improve future practice.

Nursing Home Education During the COVID-19 Pandemic.

OBJECTIVE: To help older adults living in nursing homes (NHs) while educating medical and physician assistant (MD/PA) students during the COVID-19 pandemic. METHODS: Using a multicomponent iterative process, we piloted multiple student led service-learning projects in 2 NHs and 1 hospice agency in the Midwest. Pre-post online student surveys were completed to match student interests with facility needs and to assess learning and obtain feedback regarding their experiences. RESULTS: All 12 interested students completed the initial survey; n = 23 ultimately volunteered (word of mouth); n = 11 (48%) completed the follow-up survey. Opportunities were medical record transfer, grounds beautification, resident biographies, window entertainment, and No-One-Dies-Alone program. Students averaged 9.2 volunteer hours; stated the opportunities were enjoyable, clinically applicable, and socially distanced; and reported learning about unique experiences of older adults in NHs. DISCUSSION: Despite limitations created by the pandemic, mutually beneficial and safe opportunities remain for education in the NH setting.

Virtual Reality for Therapeutic Recreation in Dementia Hospice Care: A Feasibility Study.

OBJECTIVES: To explore acceptability, tolerability, and subjective experience of virtual reality (VR) as therapeutic recreation for hospice patients living with dementia (hPLWD). DESIGN: Descriptive study setting. COMMUNITY HOSPICE AGENCY PARTICIPANTS: A convenience sample of n = 25 hPLWD cared for by a local hospice agency. INTERVENTION: Participants viewed a beach scene using VR headset for ≤30 minutes. MEASUREMENTS: Tolerability was measured with Pain Assessment IN Advanced Dementia (PAINAD)scores at baseline, every 5 minutes during VR use, and 5 minutes after headset removal. Additionally, follow-up phone calls to caregivers several hours after the intervention were performed to inquire regarding any noted adverse effect after the intervention. The subjective experience was measured with qualitative semistructured interviews with the hPLWD regarding enjoyment for the VR. Descriptive statistics were performed on all collected data. RESULTS: The VR was stopped early in 2 of the participants due to a ≥2-point increase in PAINAD score. Baseline behavioral and psychological symptoms of dementia (BPSD) were reported to have worsened in 2 (8%) of the participants at follow-up. There was no significant difference between dementia type and usage time or dementia severity and usage time. Of the 25 participants, 14 (56%) reported enjoying VR and 12 (48%) would do it again. CONCLUSION: Virtual reality use was generally safe and enjoyable in hPLWD. Virtual reality can provide meaningful activity and enhance quality of life for hPLWD at the end of life. In the future, VR may be a useful intervention for BPSD in hPLWD.

miRNAs and Müller Glia Reprogramming During Retina Regeneration.

The use of model systems that are capable of robust, spontaneous retina regeneration has allowed for the identification of genetic pathways and components that are required for retina regeneration. Complemented by mouse models in which retina regeneration can be induced after forced expression of key factors, altered chromatin accessibility, or inhibition of kinase/signaling cascades, a clearer picture of the key regulatory events that control retina regeneration is emerging. In all cases, Müller glia (MG) serve as an adult retinal stem cell that must be reprogrammed to allow for regeneration, with the end goal being to understand why regenerative pathways are blocked in mammals, but spontaneous in other vertebrates such as zebrafish. miRNAs have emerged as key gene regulatory molecules that control both development and regeneration in vertebrates. Here, we focus on a small subset of miRNAs that control MG reprogramming during retina regeneration and have the potential to serve as therapeutic targets for treatment of visual disorders and damage.

Parental alienation, coaching and the best interests of the child: Allegations of child sexual abuse in the Family Court of Australia.

BACKGROUND: Allegations of child sexual abuse provide complex challenges to family court systems. OBJECTIVES: Despite being highly criticised in the academic research, this analysis examined whether and how the gendered concepts of parental alienation syndrome or parental alienation more broadly are still being used to rebut allegations of child sexual abuse in family court cases in Australia. Parental Alienation is broadly understood as the deliberate actions of one parent to disrupt and prevent children's ongoing relationships with their other parent, in this case through allegations of abuse. METHODS: We examined 357 publicly available judgements of the Family Court of Australia between 2010 and 2015. Judgements were analysed qualitatively for key themes using N-VIVO software. RESULTS: Five themes emerged in the data, including use of the concept of parental alienation, coaching, mothers as manipulative, mothers as mentally ill, and impact of the best interest of the child. CONCLUSIONS: Results indicate that judgements made in the Family Court of Australia are both similar and divergent from those made in other jurisdictions internationally. The complexity of responding to allegations of child sexual abuse for parents is discussed.

Australian no-body homicides: Exploring common features of solved cases.

Offenders successfully disposing of a homicide victim's body creates challenges to the criminal justice process, yet no research literature exists on no-body homicide cases. We explored 25 solved homicides in Australia where no part of the victim's body was recovered. Coroners' findings, case law, and media reports from 1983 to 2017 were examined qualitatively and descriptively. Features of the cases differed based on whether the homicide was related to organized crime, serial sexual offences, or domestic violence. Challenges posed by each type of case are discussed and opportunities for solving these cases are examined.

Analysis of the CDKN2A Gene in FAMMM Syndrome Families Reveals Early Age of Onset for Additional Syndromic Cancers.

Familial atypical multiple mole melanoma (FAMMM) syndrome is a hereditary cancer syndrome that results from mutations in several genes, including the CDKN2A gene. In addition to melanoma, certain other malignancies such as pancreatic cancer are known to occur more frequently in family members who carry the mutation. However, as these families have been followed over time, additional cancers have been observed in both carriers and noncarriers. We sought to determine whether these additional cancers occur at higher frequencies in carriers than noncarriers. We performed survival analyses using 10 FAMMM syndrome families (N = 1,085 individuals) as well as a mixed effects Cox regression, with age at last visit to the clinic or age at cancer diagnosis as our time variable. This analysis was done separately for the known FAMMM-related cancers and "other" cancer groups. The survival curves showed a significant age effect with carriers having a younger age at cancer onset than noncarriers for FAMMM-related cancers (as expected) as well as for newly associated cancers. The Cox regression reflected what was seen in the survival curves, with all models being highly significant (P = 7.15E-20 and P = 5.00E-13 for the FAMMM-related and other cancers, respectively). These analyses support the hypothesis that CDKN2A mutation carriers in FAMMM syndrome families have increased risk for early onset of several cancer types beyond the known cancers. Therefore, these individuals should be screened for additional cancers, and mutation screening should be extended to more than first-degree relatives of an index carrier patient. SIGNIFICANCE: This study shows that carriers of mutations in the CDKN2A gene in FAMMM syndrome are at increased risk for early onset of several cancer types beyond the known cancers.

Murder by Pushing: An Exploratory Analysis of Homicidal Falls From a Height.

The difficulty in classifying manner of death in falls from a height provides offenders an opportunity to avoid detection by having a homicide appear otherwise. Twelve fall homicides were qualitatively examined. Results showed that most homicidal falls occurred at remote outdoor locations, were planned by offenders who were in controlling intimate relationships with the victim, and were motivated by gain. Homicide was established using inconsistencies in offender's statements and the physical evidence, inappropriate postoffense behavior, evidence of planning, and improbable alleged victim behavior. Fall homicides pose unique challenges for investigators and may negatively impact on the criminal justice process.

Assessing Police Classifications of Sexual Assault Reports: A Meta-Analysis of False Reporting Rates.

The objective of the study was to determine, through meta-analysis, the rate of confirmed false reports of sexual assault to police. The meta-analysis initially involved a search for relevant articles. The search identified seven studies where researchers or their trained helpers evaluated reported sexual assault cases to determine the rate of confirmed false reports. The meta-analysis calculated an overall rate and tested for possible moderators of effect size. The meta-analytic rate of false reports of sexual assault was .052 (95 % CI .030, .089). The rates for the individual studies were heterogeneous, suggesting the possibility of moderators of rate. However, the four possible moderators examined-year of publication, whether the data set used had information in addition to police reports, whether the study was completed in the U.S. or elsewhere, and whether inter-rater reliabilities were reported-were all not significant. The meta-analysis of seven relevant studies shows that confirmed false allegations of sexual assault made to police occur at a significant rate. The total false reporting rate, including both confirmed and equivocal cases, would be greater than the 5 % rate found here.

Collision or Collusion? Homicides Staged as Car Accidents.

A staged crime scene involves deliberate alteration of evidence by the offender to simulate events that did not occur for the purpose of misleading authorities. Staging has received little attention in the medical, legal and criminology literature, and discussions of staged car accidents are almost non-existent ­ bar a few case studies, no literature exists. The study examined 16 homicides staged as car accidents. The descriptive analysis examined common staging behaviours, and victim, offender and offence characteristics. Findings indicate staged car accidents present differently than true accidents. They often involve single vehicle, slow speed, downhill scenes, with middle-aged, female victims. Physical damage to vehicles is usually minimal, except for fire damage. Common offender behaviours include transporting the body to a vehicle, mutilation of the body, arson, and clean up. The results suggest these efforts are often unsophisticated and potentially identifiable to investigators and physicians.

Management of intestinal obstruction in advanced malignancy.

Patients with incurable, advanced abdominal or pelvic malignancy often present to acute surgical departments with symptoms and signs of intestinal obstruction. It is rare for bowel strangulation to occur in these presentations, and spontaneous resolution often occurs, so the luxury of time should be afforded while decisions are made regarding surgery. Cross-sectional imaging is valuable in determining the underlying mechanism and pathology. The majority of these patients will not be suitable for an operation, and will be best managed in conjunction with a palliative medicine team. Surgeons require a good working knowledge of the mechanisms of action of anti-emetics, anti-secretories and analgesics to tailor early management to individual patients, while decisions regarding potential surgery are made. Deciding if and when to perform operative intervention in this group is complex, and fraught with both technical and emotional challenges. Surgery in this group is highly morbid, with no current evidence available concerning quality of life following surgery. The limited evidence concerning operative strategy suggests that resection and primary anastomosis results in improved survival, over bypass or stoma formation. Realistic prognostication and involvement of the patient, care-givers and the multidisciplinary team in treatment decisions is mandatory if optimum outcomes are to be achieved.

Cyanobacterial blooms: statistical models describing risk factors for national-scale lake assessment and lake management.

Cyanobacterial toxins constitute one of the most high risk categories of waterborne toxic biological substances. For this reason there is a clear need to know which freshwater environments are most susceptible to the development of large populations of cyanobacteria. Phytoplankton data from 134 UK lakes were used to develop a series of Generalised Additive Models and Generalised Additive Mixed Models to describe which kinds of lakes may be susceptible to cyanobacterial blooms using widely available explanatory variables. Models were developed for log cyanobacterial biovolume. Water colour and alkalinity are significant explanatory variables and retention time and TP borderline significant (R2-adj=21.9%). Surprisingly, the models developed reveal that nutrient concentrations are not the primary explanatory variable; water colour and alkalinity were more important. However, given suitable environments (low colour, neutral-alkaline waters), cyanobacteria do increase with both increasing retention time and increasing TP concentrations, supporting the observations that cyanobacteria are one of the most visible symptoms of eutrophication, particularly in warm, dry summers. The models can contribute to the assessment of risks to public health, at a regional to national level, helping target lake monitoring and management more cost-effectively at those lakes at the highest risk of breaching World Health Organisation guideline levels for cyanobacteria in recreational waters. The models also inform restoration options available for reducing cyanobacterial blooms, indicating that, in the highest risk lakes (alkaline, low colour lakes), risks can generally be lessened through management aimed at reducing nutrient loads and increasing flushing during summer.

Principles of transitional care for young people with longstanding continence problems.

Medical advances over the past 30 years mean that increasing numbers of children with long term conditions are surviving to adulthood. This means the way transitional care from paediatric to adult services is managed has become a focus of debate. This article discusses the process of healthcare transition for young people who have continence problems or require long term bladder management in their adult life.

Air pollution and health in Scotland: a multicity study.

This paper presents an epidemiological study investigating the effects of long-term air pollution exposure on public health in Scotland, focusing on the 4 major urban areas, Aberdeen, Dundee, Edinburgh, and Glasgow. In particular, the associations between respiratory hospital admissions in 2005 and exposure to both PM(10) and NO(2) between 2002 and 2004 are estimated using a small-area ecological design. The implementation of such studies requires careful consideration of a number of statistical issues, including how to model spatial correlation, identifiability of the model parameters, and the possible effects of ecological bias. The results show that long-term exposures (over 3 years) to PM(10) and NO(2) are significantly associated with respiratory hospital admissions in Edinburgh and Glasgow, whereas the risks for Aberdeen and Dundee are generally positive but nonsignificant.

Strategies for monitoring and managing mass populations of toxic cyanobacteria in recreational waters: a multi-interdisciplinary approach.

Mass populations of toxin-producing cyanobacteria commonly develop in fresh-, brackish- and marine waters and effective strategies for monitoring and managing cyanobacterial health risks are required to safeguard animal and human health. A multi-interdisciplinary study, including two UK freshwaters with a history of toxic cyanobacterial blooms, was undertaken to explore different approaches for the identification, monitoring and management of potentially-toxic cyanobacteria and their associated risks. The results demonstrate that (i) cyanobacterial bloom occurrence can be predicted at a local- and national-scale using process-based and statistical models; (ii) cyanobacterial concentration and distribution in waterbodies can be monitored using remote sensing, but minimum detection limits need to be evaluated; (iii) cyanotoxins may be transferred to spray-irrigated root crops; and (iv) attitudes and perceptions towards risks influence the public's preferences and willingness-to-pay for cyanobacterial health risk reductions in recreational waters.

Impacts from repeated mass media campaigns to promote sun protection in Australia.

Campaigns using television, radio and print media were conducted over three summers in New South Wales, Australia, aiming to increase the use of sun protection measures among children under 12 years. The evaluation entailed cross-sectional telephone surveys before and after each of the first two campaigns and following the third campaign. The study group were parents of children under 12 years. Random digit dialling yielded samples of approximately 800 for each survey. Measures addressed campaign recall and sun protection knowledge, attitudes and behaviours. The surveys revealed significant levels of campaign recall. Knowledge about the protective benefits of sunscreens, hats and protective clothing was high at baseline and showed little improvement over the campaigns. Knowledge levels about the benefits of shade cover and of the relative risks of skin cancer from childhood sun exposure were lower, and also did not show improvement. Just one of the four attitude factors showed significant improvement, and this concerned the importance that parents placed on the issue of child sun protection. After the final campaign there were increases compared with baseline in childrens' use of sunscreen, protective clothing and shade, but it was notable that between campaigns levels of these behaviours were similar to or below those at baseline. There was no evidence of a campaign-related increase in hat wearing by children. All sun protection measures were used less often by adults than children, but these showed similar trends. Mass media campaigns may contribute to short-term increases in some sun protection behaviours; however, as their impact is not sustained they should be repeated and supplemented by educational, policy and environmental strategies.